MEDICARE: ATHENA DENTAL GROUP PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019.028622	IL

General Provider Information

NPI Number	:	1689129637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHENA DENTAL GROUP PC

Provider Business Mailing Address
First Line	:	724 E NORTHWEST HWY
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-3442
Country	:	US
Telephone Number	:	857-544-2482
Fax Number	:

Provider Business Practice Location Address
First Line	:	724 E NORTHWEST HWY
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-3442
Country	:	US
Telephone Number	:	857-544-2482
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	DR. AVANTI SANGHAVI
Credential	:	DDS
Telephone Number	:	857-544-2482

Provider Enumeration Date	:	08/19/2016
Last Update Date	:	08/19/2016

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